Injury of facial nerve, unspecified side, initial encounter

This code signifies damage to the seventh cranial nerve (facial nerve) without specifying the affected side of the face. Such an injury can lead to facial muscle weakness or paralysis, impacting expressions, eye closure, and speech articulation. The "initial encounter" designation indicates the patient is receiving active treatment for the acute injury.

Apply this code when documentation clearly indicates an injury to the facial nerve, but the specific side (right or left) is not yet determined or recorded. This is appropriate for initial evaluations in the emergency department or first clinic visits following trauma. Supporting documentation would include physician notes detailing facial nerve palsy or weakness following an injury, without laterality specified.

• Do not use this code if the laterality of the facial nerve injury (right or left) is documented; instead, select a more specific code from the S04.5- series.
• Ensure the "initial encounter" seventh character is appropriate for the patient's current phase of care. Subsequent encounters would use "D" or "S".
• Distinguish this from facial nerve disorders of non-traumatic origin, such as Bell's palsy (G51.0), which are coded elsewhere.